Archivio Italiano di Urologia e Andrologia 2018; 90, 3220 CASE REPORT Management of self-inflicted orchiectomy in psychiatric patient. Case report and non-systematic review of the literature Marco Garofalo 1, Alessandro Colella 1, Paolo Sadini 1, Lorenzo Bianchi 1, Giacomo Saraceni 2, Eugenio Brunocilla 1, Giorgio Gentile 3, Fulvio Colombo 3 1 Department of Urology, Sant’Orsola Hospital - University of Bologna, Bologna, Italy; 2 Complex Pelvic Surgery Unit, Department of Gynecology and Urology, Sant'Orsola-Malpighi Hospital, Bologna, Italy; 3 Andrology-Unit, Sant’Orsola Hospital - University of Bologna, Department of Gynecology and Urology, Bologna, Italy. . Introduction: Self-inflicted orchidectomy and auto-castration, also known as “Eshmun complex” is a rare phenomenon. The aim of our study it to present the management of a patient who performed a self orchiectomy and propose a non-systematic review of literature about self-orchiectomy. Material and method: A 27-years old male Patient with psychi- atric disorder was admitted to our ward to have been cutted his scrotum with scissors and cut away his left testicle causing active bleeding from the left spermatic artery. The patient underwent emergency surgery with clamping of the spermatic cord and hemostasis of the wound. Results: After surgery the clinical condition of the patient remained good during whole hospitalization. Urgent psychiatric evaluation was performed in order to administer proper thera- py for acute management. To best of our knowledge, only 11 cases of self-orchidectomy are reported in literature and all of them except 1 case, underwent surgical exploration. Conclusions: Self-orchidectomy is an extremely rare phenome- non, often associated with psychiatric disorders, compounded by the use of drugs. In our opinion, emergency surgery should be the first choice of treatment, offering diagnostic and hemo- static purpose in a single act, aimed to prevent acute and post- acute complications. KEY WORDS: Self orchiectomy; Genital mutilation; Self castration. Submitted 15 May 2018; Accepted 26 July 2018 Summary No conflict of interest declared. no mental illness history (8, 9). Risk factors for GSM include: commanding hallucinations, religious delusions, substance abuse and social isolation (5, 10, 11). It has been reported a correlation between schizophrenia (or its acute state induced/flared by drugs abuse and acute psychotic states induced by recreational drugs consump- tion) and major self-mutilations (12, 13); sometimes gen- ital mutilation can also be the presenting sign of schizo- phrenia (14). Auto-castration in a setting of drugs abuse alone, especially of a single drug (mainly methampheta- mine and cannabinoids) and within absence of a certified mental illness history, has also been described (15-17). The vast majority of reported cases have occurred among single, white males in their 20s and 30s (18). Usually, patients report all the common signs in trau- matic amputation of the testis (namely, exposed lacerat- ed wound, avulsion, etc). In addition, very few other cases show genital auto-mutilation of one or both testi- cles without involving the penile shaft. We show a case of unilateral self-orchidectomy performed in a “surgical fashion”, resulting in a closed wound acute scrotum pres- entation. The aim of our study it to present the manage- ment of a patient who performed a self-orchiectomy; we also propose a non-systematic review of literature about self-orchiectomy. MATERIALS AND METHODS 21.03.2017. 03:12 p.m. A 27-years old male Patient, voluntarily admitted to St. Orsola Malpighi Hospital’s Casualty Ward, asking for medical assistance for referred “scrotal bleeding and self-orchidectomy”. Patient was already admitted before, since he was followed by a psy- chiatric clinic due to schizophrenia, not properly adher- ent to Fluphenazine prescription. The patient lucidly reported his psychiatric disorder at beginning of medical consultation and he reported that he incised his scrotum with scissors and cut away his left testicle, then he sutured his scrotum by himself. He had no mention of local anesthesia or analgesic usage. Genital examination revealed globally swollen and round scrotum (approximately 15 cm). Scrotal skin, looking stretched, dehydrated and clean, was involved by a large DOI: 10.4081/aiua.2018.2.220 INTRODUCTION Self-inflicted testicular injury is a rare phenomenon, with less than 200 cases reported in literature (1). Scrotal traumas are included in a different genital self-mutilation (GSM) setting, with lesions varying from tissues lacera- tion to ablation of the whole external genitals (2). Most self-inflicted testicular injuries have been reported in trans-sexual patients who desire emasculation (3) or by psychotic patients with either functional or organic brain disease (4, 5). Self-inflicted orchidectomy and auto-castration, also known as “Eshmun complex” (6, 7) is a type of major-self- mutilation (MSM) common among young individuals affected by psychiatric disorders, especially during acute psychotic state (1). This traumatic injury is less common in delusional and depressed individuals or in subject with Garofalo_Stesura Seveso 03/10/18 09:49 Pagina 220 221Archivio Italiano di Urologia e Andrologia 2018; 90, 3 Management of self-inflicted orchiectomy in psychiatric patient ecchymosis more evident on the lower-left side. Indeed, on the left side, at lower-middle third, a cutaneous sutur- ing measuring approximately 1 x 0.5 cm appeared as repaired by suturing stitches made of common cotton thread (Figures 1a, 1b). Ultrasound evaluation by scrotal eco-color-Doppler (ECD) has been performed, according to the casualty ward’s dedicated acute scrotum diagnostic protocol. The ECD showed a normal, despite dislocated, right testicle (Figure 2a) and an extensive hematoma of the left scro- tum cavity with a modest color-Doppler signal within its content, but no evaluable left testicle (Figure 2b). Blood exams were indicative for acute infection and inflammation (White blood cells: 19.01 x 10^9/L; Neutrophils: 16.13 x 10^9/L); toxicological screening found high amounts of plasmatic cannabinoids (69 ng/mL). Total hemoglobin was 13.8 g/dL. within normali- ty ranges of Hematocrit and Red Blood Cells total amount. Basing on this preliminary data, in absence of major bleeding, considering the regular Glasgow Coma Scale (GCS) and mental status, himself showing a calm and cooperative behavior, we aimed firstly to determine the entity of lesion, the extent of active bleeding and the need of acute management by surgical exploration. Examination was extended through palpation and manipulation of external genitals, revealing a scrotal fis- tula covered by uneven wire stitching on the left scrotal sack. By applying progressive non-traumatic digital pres- sure, the left scrotum was evacuated from an approxi- mate amount of 400 ml of blood clots and serous/hemat- ic material through the un-sutured scrotal breech. This maneuver allowed palpation of scrotal content. Therefore, surgical scrotal exploration was planned in emergency, with the consent of the informed patient. Antibiotic prophylaxis was administered by endovenous infusion of cefuroxime 2 gr. First, we removed some black cotton double-wired single-suturing stitches overlapping each other in the left scrotum, assumed to be placed with a sewing needle. So, an irregular circular area of excision of 4 cm involving all scrotal wall tissues, appeared. Scrotal incision margins presented as neat as a single or few scis- sor section lines. Evacuation of approximately 100 ml of blood clots revealed an empty left hemiscrotum. An active bleeding sprouting was individuated from the left sper- matic artery; this revealed the distal portion of the left spermatic chord (Figures 3a, 3b), suggesting that the sper- matic chord incision has been conducted by the patient above the testicular veins; no testicular or epididimal rem- nants were found. Didymus and epididymis were missing: in fact, the patients referred in follows consultation, that he threw the testis into the toilet. After clamping and dissection of distal amputated sper- matic chord, the vessels and the vas deferens were sutured separately with 2-0 Vicryl®. After washing the cavity, the hemostasis check showed no further bleeding and no other trauma. A percutaneous suction drainage has been placed in the left scrotal cavity. Finally, the scro- tum has been repaired by suturing the Dartoic plane and the skin in 4-0 SafilQuick® absorbable single stitches. RESULTS After surgery, the clinical condition of the patient remained good during whole hospitalization. Intravenous fluids, anti-inflammatory drugs and analgesic have been adminis- tered. The day after the surgical intervention, the vital signs were good and stable; Hemoglobin values of 11.0 g/dL in the first postoperative day, lined with the blood loss before the hemostasis in the operating theatre (Estimating Blood Loss: 150 cc) and the inflammation signs were con- siderably reduced (White Blood Cells 8.92 x 10^9/L). There was no fever, no local or systemic infection and good status of the surgical wound. Urgent psychiatric evaluation was performed in order to administer proper therapy for acute management. The patient referred during the Psychiatric evaluation that his act was impelled by voices inside his head, and probably this escalated quickly with chronic and acute abuse of cannabinoids. Moreover, he said that he felt no pain during the mutilation. Since the surgical postopera- Figure 1. Preoperative picture of the scrotum, with the surgical suture made by the patient. Figure 2. Ultrasound of scrotum: a) right scrotum with regular right testis b) left scrotum, without the testis. Figure 3. Intraoperative picture: the cut funiculus. A. B. A. B. A. B. Garofalo_Stesura Seveso 03/10/18 09:49 Pagina 221 Archivio Italiano di Urologia e Andrologia 2018; 90, 3 M. Garofalo, A. Colella, P. Sadini, L. Bianchi, G. Saraceni, E. Brunocilla, G. Gentile, F. Colombo 222 tive convalescence elapsed without complication, the patient was transferred to a psychiatric ward. DISCUSSION GSM is a rare phenomenon. The most common self-muti- lating behavior is cutting one’s own wrist, which is usual- ly committed by adolescents or by the mentally retarded for attention-seeking purposes. Rarely, self-mutilation has a serious scenario that leads the patient to attempt to amputate his penis, to castrate himself, to extract his eye or to amputate his hand (19). The instruments that have been used include kitchen knives, blades, scissors, a chainsaw and an axe. Most of cases reported in the litera- ture, consist of patients with psychosis or psychiatric dis- orders with either functional or organic brain disease. Such cases have been observed in schizophrenia or depression, and it is sometimes difficult to diagnose these conditions because such a behavior is usually the only pre- senting symptom of the psychiatric disorder. However, few cases have been described in non-psychotic persons. It has been suggested that there is no difference in the severity of the self-inflicted injuries between psychotic and non-psychotic patients. In our case report, the reason for self-mutilation of the testis was the status of schizophrenia compounded by the use of drugs. As the degree of mutilation varies, so does the treatment, which can be complex and quite challenging; it often consists of a multidisciplinary management between the urologist, psychiatrist, psychologist and primary care physician. Early diagnosis and fast treatment can reduce the acute and post-acute complications (blood loss, infections, hemorrhagic shock…). To best of our knowl- edge, only 11 cases of self-orchidectomy are reported in literature and all of them except 1 case, underwent sur- gical exploration (Table 1). The main goal of surgical treatment includes restoration of the anatomy and function of mutilated organs, as much as possible. A superficial laceration may require no more than simple suturing; a serious injury with self- mutilation of organ or part of it, as we reported in the present case report, needs an emergency intervention. Complications resulting from GSM vary according to the severity of the injury inflicted and the extent of surgical repair undertaken. CONCLUSIONS Self-orchidectomy is an extremely rare phenomenon, often associated with psychiatric disorders, compounded by the use of drugs. In our opinion, emergency surgery should be the first choice of treatment, offering diagnos- tic and hemostatic purpose in a single act, aimed to pre- vent acute and post-acute complications. However, a multidisciplinary approach is essential and includes a careful psychiatric evaluation to avoid recurrences and to more extensively support these patients through their mental and physical integrity recovery. REFERENCES 1. Veeder TA, Leo RJ. 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Psychiatry 2008;50:285–7 Correspondence Marco Garofalo, MD marco.garofalo@unibo.it Alessandro Colella, MD alessandro.colella@studio.unibo.it Paolo Sadini, MD sadini@libero.it Lorenzo Bianchi, MD lorenzo.bianchi3@gmail.com Eugenio Brunocilla, MD eugenio.brunocilla@unibo.it Department of Urology, Sant’Orsola Hospital - University of Bologna, Bologna, Italy Giacomo Saraceni, MD giacomo.sareceni@libero.it Complex Pelvic Surgery Unit, Department of Gynecology and Urology, Sant'Orsola-Malpighi Hospital, Bologna, Italy Giorgio Gentile, MD (Corresponding Author) dr.giorgio.gentile@gmail.com Fulvio Colombo, MD fulvio.colombo@aosp.bo.it Andrology-Unit, Sant’Orsola Hospital - University of Bologna, Department of Gynecology and Urology, Bologna, Italy Garofalo_Stesura Seveso 03/10/18 09:49 Pagina 223